Provider Demographics
NPI:1386630663
Name:GOEDKEN, MARK J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:GOEDKEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1515 42ND ST NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-3061
Mailing Address - Country:US
Mailing Address - Phone:319-365-7581
Mailing Address - Fax:319-365-0163
Practice Address - Street 1:1515 42ND ST NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-3061
Practice Address - Country:US
Practice Address - Phone:319-365-7581
Practice Address - Fax:319-365-0163
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2022-06-23
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Provider Licenses
StateLicense IDTaxonomies
IA31916207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4140400Medicaid
IA4140400Medicaid
IA15468Medicare PIN